Tony Beddow is eagerly awaiting details of the government's promised consultation paper on clinical governance.
As chief executive of Morriston Hospital/Yysbyty Treforys trust, Swansea, he found out what it was like to take on the medical profession. The backlash made his own position untenable, and he resigned.
Now a senior fellow at the Welsh Institute of Health and Social Care, Mr Beddow's appetite has been whetted by the light shed on the bare proposals given in The New NHS white paper by health minister Alan Milburn (see box).
The key features are that trusts will have a new 'legal duty of quality', with chief executives ultimately accountable.
'It is an interesting concept, ' says Mr Beddow. 'I would be interested to see what authority goes with the responsibility. Or is this once again managers being given accountability without the ability to address it?'
Most important is whether chief executives will be accountable for ensuring systems are in place and adequately resourced, or whether they will be responsible for the performance of professionals operating in the systems.
'We are moving into areas where managers are being edged towards a professionalisation of their calling. That will provoke an interesting sharing of territory in things like ethical bases and common standards of performance.'
The interests of clinicians and others will have to be delineated, he says. Otherwise, 'we will continue to have some of the uncertainty and potential for using particular groups as lightning conductors when things go wrong'.
Lionel Joyce, chief executive of Newcastle City Health trust, is also unsure whether the necessary tools will be there. But he has no doubt about the overall policy.
'I think it is great. It gives a legitimacy and authority for the sort of responsibility that the best have always encouraged, ' he says. 'It makes explicit our responsibility for clinical care.'
Mr Joyce says current arrangements for encouraging doctors who are not performing to quality standards to go elsewhere are both discrete and 'slightly dodgy' because of their status as independent practitioners.
'I do see difficulties, ' he says. 'It goes to the heart of how we do our job. You are responsible for everything that goes on in this organisation, particularly the quality of clinical care.'
He adds : 'What is the point of being a chief executive if you are not concerned about quality of care? It is what we are here for.'
But the legislation needs to help chief executives with their responsibilities, he says. Professional self-regulation works, but it is slow and hard work. Perhaps the balance is still too much in favour of the individual, he says.
NHS Confederation chief executive Stephen Thornton thinks Mr Milburn should have focused more on the positive parts of his quality agenda instead of highlighting the new legal duty.
'The theory is excellent. The principle is a good one. NHS trusts need to be held accountable for clinical services.
But recourse to the law benefits lawyers.
Let's get it right first time rather than ending up in court, ' he says.
Richard Higgins, chief executive of Parkside Health trust in West London, is enthusiastic. He points out that his only legal duty at present is for finance and welcomes the additional responsibility for quality of services.
'It will make us ask a series of questions such as, do we understand what is the right thing to do, do the staff know and are they being trained and supported to do it? And once we've asked all the questions about what we should be doing the final question is, how was it for patients, users, clients?'
He says the proposals will give chief executives and trust boards more interest in good practice. It will also endow them with the authority to make sure that good practice is followed, as well as offering incentives to managers.
It is already possible to get rid of poorly performing doctors, but that 'isn't always straightforward or easy', he says.
That could be changed by legislation, but work is already going on between the British Medical Association and the royal colleges to produce better systems to detect, support and improve the work of under performing doctors. BMA chair Sandy Macara is 'very supportive of the new quality framework' and wants a robust system. That should ensure that court action against doctors will be rare, he says.
What Alan Milburn said Trusts will have a 'legal duty of quality' complemented by a 'new framework of clinical governance'.
All hospitals will have 'a doctor, nurse or other clinical professional to take charge of quality issues'.
Trust boards will get regular reports on quality and annual reports on clinical governance.
Clinical governance will apply 'just as much' in primary and community care as in the acute sector.
'Balancing the books remains important, but quality of care to patients should be the first priority.'
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